Emilio Wagner

Change in plantarflexion strength after complete detachment and reconstruction of the Achilles tendon.

Background: Chronic insertional tendinitis of the Achilles tendon is an overuse injury seen with increasing frequency because of an aging population and an increased interest in sports. We evaluated the change in plantarflexion strength in patients after our surgical technique for chronic insertional Achilles tendinitis. Methods: From our previous clinical series of detachment and reconstruction of the Achilles tendon for the treatment of insertional tendinitis, ten patients were evaluated with an average followup of 32.1 (range 18 to 52) months. The average age was 65.7 years. We developed a mathematical model to predict the difference in plantarflexion strength between a reconstructed ankle and a healthy contralateral one. Isokinetic testing at 60 degrees/second was performed, measuring plantarflexion peak torque, dorsiflexion peak torque, and total work. Results: Our mathematical model predicted a decrease of 4% in plantarflexion torque after the surgery. Isokinetic testing found no significant differences in plantarflexion torque, dorsiflexion torque, or total work between the operated and nonoperated ankles. Conclusions: Complete detachment and reconstruction of the Achilles tendon do not decrease the working capacity of the gastrocsoleus muscle.

Rotational Osteotomy for Hallux Valgus. A New Technique for Primary and Revision Cases

More than 200 different surgical techniques exist for hallux valgus (HV). Some of them are designed for mild, moderate, or severe deformities depending on their correction power. Nevertheless, they all correct only the coronal and/or sagittal plane deformity. Just a handful of them correct the known axial malrotation that exists in most HV cases. This malrotation is one possible factor that could be the source of recurrence of an operated HV as it has been described. We describe a new technique which simultaneously corrects the metatarsal internal rotation and varus deformity by rotating the metatarsal through an oblique plane osteotomy. This is performed with no bone wedge resection. Also, there is a broader bone surface contact than on a transverse proximal osteotomy. This technique is easy to remember and relatively simple to perform in primary and revision cases. The authors results show that it is as safe and effective as other procedures, with some advantages to be discussed. Levels of Evidence: Diagnostic Level 5. See Instructions for Authors for a complete description of levels of evidence.

Plate position and angular stability: mechanical comparison in sawbone osteotomy models.

Proximal metatarsal osteotomies are inherently unstable and difficult to fix. The purpose of this study was to compare the mechanical stiffness in sawbone models of medially versus dorsally placed plates and then to compare semilocked versus nonlocked plates in different osteotomy configurations. Thirty sawbone models were constructed, fixed either with titanium self-locking or steel mini-fragment plates. They were divided in groups and their stiffness was measured. The stiffness of any model fixed with medial titanium or steel plates was on average 158% and 228% greater, respectively, compared to dorsal plates. Adding a dorsal shelf of bone to a proximal closing wedge osteotomy increases its stiffness. Using locked plates increased the mechanical stiffness in only one configuration. The article suggests that models fixed with medial plates have greater resistance to failure than models fixed with dorsal plates. Using locked plates does not increase the mechanical stiffness of the construct.

Hallux Varus and Plantar Plate Repair

One of the most frequent problems encountered in foot and ankle are hallux valgus and lesser toes deformities. One of the complications after hallux valgus treatment is a iatrogenic hallux varus. This deformity can be solved at 2 levels, namely the skeletal level, through a metatarsal osteotomy to correct the varus component of the bone and at the soft tissue level, to compensate and rebalance soft tissue tension surrounding the metatarsophalangeal (MTP) joint. The soft tissue reconstruction may include capsular releases, capsulorraphies, tendon transfers, and augmentations such as nonreabsorbable suture reinforcement of some MTP capsular components. Lesser toe deformities have historically shown moderate to low levels of satisfaction after surgical treatment. Ten years ago the MTP component of lesser toes deformity was solved with some type of metatarsal shortening osteotomy and soft tissue release, specially including dorsal structures over the metatarsal head. Over the last few years’ knowledge from a series of articles have shown the importance in recognizing and repairing the MTP plate to regain stability and alignment at the joint. Different alternatives of repair exist at this level, and some of them are discussed in this article. Level of Evidence: Diagnostic Level 5. See Instructions for Authors for a complete description of levels of evidence.

Proximal Rotational Metatarsal Osteotomy for Hallux Valgus: Technique Description and Prospective Case Series

Category: Bunion, Midfoot/Forefoot Introduction/Purpose: Hallux valgus combines two deformities, the metatarsus varus and metatarsal internal rotation. The rotational deformity is seldom corrected during surgery, but is a known recurrence factor. Most techniques only correct the metatarsus varus (scarf, chevron, etc). We present a prospective case series using a novel metatarsal rotational osteotomy called PROMO (proximal rotational metatarsal osteotomy) which simultaneously corrects the metatarsal internal rotation and varus deformity by rotating the metatarsal through an oblique plane osteotomy. This is performed with no bone resection. Our objective was to report this new technique, preliminary results, its advantages and complications. Methods: 20 consecutive patients (17 women) with Hallux Valgus, average age 45 (25-55), were operated using this technique. The average preoperative intermetatarsal angle (IMA) was 15 degrees with an average Hallux internal malrotation of 30 degrees and a sesamoid malposition of grade V or more in all cases. Postoperatively, sesamoids position, Hallux rotation, IMA and metatarsal length were registered. They were followed for 1 year (8-14 months). The surgical technique is described, with its potential benefits and drawbacks. The radiological outcome, postoperative LEFS score, recurrence rate (IMA increase >5 degrees) and complications were registered. Results: Well positioned sesamoids (grade IV or less) were obtained in all patients postoperatively, with a complete Hallux rotational correction. Postoperative IMA was 5 degrees. achieving a complete metatarsal varus correction. No metatarsal shortening was observed whatsoever. No recurrence has been observed until final follow up. Preoperative and postoperative LEFS scores were 58 and 73 respectively. Conclusion: The PROMO has the advantage over other osteotomies that it can reliable correct, both metatarsal malrotation and varus deformities, achieving a complete deformity correction and hopefully decreasing recurrence rate. The surgical technique has been studied and refined extensively, in order to simplify it and make it reliable. Although more patients and follow-up are needed, the authors believe it is a promising surgical technique which addresses a previously not considered hallux valgus deformity component.

Early Weight Bearing on Weber C Fractures with Retained Syndesmotic Screws

Category: Ankle, Sports, Trauma Introduction/Purpose: There is no consensus about when to allow weight bearing in ankle fractures treated with syndesmotic screw fixation. There has been no evaluation of the radiographic fate of the syndesmosis when syndesmotic screws are retained and early weight bearing is encouraged, or the clinical result depending on the screw status, which can be intact, broken or loose. Our objective was to evaluate the radiographic and clinical parameters of patients who had a screw fixation of the syndesmosis and early weight bearing was allowed. Our hypothesis was that no difference would be observed on syndesmotic reduction or clinical function depending on the screw status. Methods: We analyzed 42 patients with ankle fractures treated with syndesmotic screws in which early weight bearing was allowed (3 weeks postoperatively). Weight bearing radiographs were obtained at 2 weeks, 2 months and at final follow up (41.2 months). Radiologically we measured medial clear space (MCS), tibiofibular overlap (OL), tibiofibular clear space (CS), talar shift (TS) and screw condition (intact, broken, loose). Clinical function was measured with the AOFAS score and stratified by the screw condition. Statistical analysis was performed with the SPSS software and a non-inferiority confidence interval for the mean was calculated. Results: At final follow up, 66,6% of the screws were broken, 30,9% showed significant loosening and only 1 patient (4,7%) had a screw that remained solid with no signs of osteolysis. MCS at 2 weeks, 2 months and at final follow up was 2,94 mm; 3,03 mm; 3,02, respectively. OL was 6,76 mm; 6,78 mm; 6,83 and CS was 4,26 mm; 4,66 mm; 4,6 mm. No TS was detected. There was no difference in measurements along time (p>0,05). Relative to clinical function, the mean AOFAS score was 95 points. No difference was found between the clinical scores of patients stratified by the screw condition (p>0,05). Conclusion: Early weight bearing on a fixed syndesmosis appears to be safe, with no measurable radiographic or clinical consequences regarding ankle joint function. Despite screw breakage or loosening on x-rays, loss of reduction is seldom observed. We suggest that routine removal of syndesmotic screws is not necessary in these group of patients.

Posterior tibial tendon transfer: Biomechanical evaluation of circumtibial, above-retinaculum and below-retinaculum transmembranous transfer

Category: Ankle, Basic Sciences/Biologics, Tendon Transfer, Dropfoot Introduction/Purpose: Posterior tibial tendon transfer (PTTT) is performed for a variety of pathologies where loss of dorsiflexion is compensated by the transfer, e.g. cavus foot, neurologic foot (dropfoot), etc. Transfers can be performed subcutaneously through a circumtibial way or deeply through the interosseous membrane (transmembranous). The latter is classically routed above the extensor retinaculum. We evaluated the circumtibial (CT), above-retinaculum transmembranous (ART) and below-retinaculum transmembranous (BRT) transfers gliding resistance and kinematics in a cadaveric model during ankle range of motion (ROM). Our first hypothesis was that the CT would be the transfer with more gliding resistance and with more kinematic alteration. Our second hypothesis was that the ART would not show significant differences against the BRT transfer. Methods: 8 cadaveric foot- ankle – distal tibia were prepared, identifying all extensor and flexor tendons proximally. The skin and subcutaneous tissue were kept intact. Each specimen was mounted on a special frame, and luminous markers were attached to the skin to adapt it to the Oxford Foot Model. A dead weight equal to 50% of the stance phase force was applied to each tendon, except for the Achilles tendon. Each specimen served as its own control, testing dorsiflexion when pulling the tibialis anterior (TA), recording the kinematics and gliding resistance. Then, dorsiflexion was tested with the transfers already described (CT, ART and BRT PTTT). A 10-repetition cycle of dorsiflexion and plantarflexion was performed for each condition. The movement of the foot was recorded using high speed cameras, and the force needed to achieve dorsiflexion was registered in every cycle. Statistical analysis was performed using the SPSS software. Results: The circumtibial transfer showed the highest gliding resistance (p<0.05). The ART and BRT transfers increased the least the gliding resistance over the control, with no difference between them (p>0.05). Regarding kinematics, all transfers decreased ankle ROM, being the CT transfer the condition with less range of motion (-9 degrees, p<0.05). ART and BRT transfers did not show differences relative to ankle ROM among them. The CT transfer significantly produced more supination of the forefoot over the hindfoot (p<0.05). The ART and BRT transfers did not differ from the control group relative to supination/pronation. Finally all the transfers produced a significant abduction motion of the forefoot compared to the control, with no difference between them. Conclusion: The circumtibial transfer had the highest tendon gliding resistance and the worst kinematics of all transfers. It achieves less dorsiflexion and in an inverted position. Interestingly, there was minimal difference in gliding resistance between the above and below retinaculum transmembranous transfers. Per our results, we suggest that when performing a PTTT the transmembranous route should be the transfer of choice. The potential bowstringing effect which may be painful and not cosmetic for patients when performing a PTTT subcutaneously (ART) could be avoided if the transfer is routed under the retinaculum, without significant compromise of the final function.

Muscular Vein Thrombosis Previous to Immobilization in Acute Tendo Achilles Rupture: Case Report and Review of Literature

Category: Ankle Introduction/Purpose: Thromboembolic complications during lower-limb immobilization after Achilles tendon ruptures are common. Both operative and nonoperative treatments of Achilles rupture include a period of immobilization which is a well- documented risk factor for distal vein thrombosis. Curiously, there is a gap in literature linking the diagnosis of thromboembolic events to the Achilles rupture previous to the inmobilization. The term DTV refers to the anterior/posterior tibial or the peroneal veins, i.e. those that correspond to arterial structures and comprise the profound vein system. Although still with little agreement, the role of muscular vein thrombosis or isolated gastrocnemius or soleus vein thrombosis are gaining relevance within the current published data, despite there is no report of it association with tendo Achilles rupture before or after the initiation of treatment. Methods: Case report: Five consecutive patients with a diagnosis of traumatic Achilles rupture were evaluated. All patients sustained non traumatic injuries. One of the patients was a heavy smoker, and two of them had BMI over 25. We routinely execute an ultrasound to locate the rupture site and at the same time color ultrasound Doppler was performed by an expert in vascular echography, before the initiation of treatment. In all cases a thrombosis of the calf muscle veins was found. Surgical treatment was not advice in any of the patients and definitive treatment was conservative. Results: Calf muscle veins are deep veins in the distal lower extremity that are nonpaired and not associated with named tibial arteries. These veins make up a complex venous system of the musculature of the posterior leg and include the soleal and gastrocnemius veins that run as sinusoids within the muscles of the same name. The soleal sinusoids may drain into the midperoneal or posterior tibial veins, whereas the gastrocnemius sinusoids may empty directly into the popliteal vein. Although the real incidence of MVT is extremely variable, in patients presenting with symptoms and signs suspicious for distal vein thrombosis, muscular veins have been shown to be the most common location for thrombosis with 23% to 41% of all patients. Conclusion: Our group of patients was diagnosed before immobilization was established. One plausible explanation could be that the muscle trauma associated with the tendinous rupture may have some influence in the thrombi generation triggering endothelial dysfunction, or affecting the calf muscle pump creating venous stasis, conditions that favour the VTE appearance. It is our perspective that although not well stablished there is at least a theoretical risk of further propagation to the profound venous system and subsequently to the pulmonary system, and this fact not only conditions the treatment of MVT itself, but also the treatment of the Achilles rupture.

Case Report: Spontaneous Rupture of the Ankle Extensor Retinaculum

Spontaneous rupture of the extensor retinaculum of the ankle is a rare condition, only reported a few times in the literature. We present a case report of a spontaneous rupture of the ankle extensor retinaculum, which was reconstructed with a fascia lata autograft, along with a discussion of the literature.

Arthrodesis of the Hallux Metatarsophalangeal Joint

Introduction Arthrodesis of the first metatarsophalangeal joint is the most reliable surgical option, with a low complication rate, for hallux rigidus from end-stage osteoarthritis. Step 1 Surgical Approach Make a medial approach, following the mid-axis of the joint. Step 2 Joint Preparation Using a cup-cone configuration provides excellent bone exposure, construct stability, and metatarsophalangeal joint congruity. Step 3 Positioning of Arthrodesis Fix the toe in 5° to 10° of valgus and elevated 5 mm from the floor to achieve desired dorsiflexion. Step 4 Application of Implants Achieve a stable construct with a crossed lag screw and a dorsal locking plate (a hybrid construct). Step 5 Closure Perform a standard soft-tissue closure. Step 6 Postoperative Care Allow weight-bearing as tolerated after two weeks and impact exercises only after bone healing has been shown on radiographs, which can take up to ten weeks. Results Arthrodesis of the metatarsophalangeal joint in the hallux provides good results in terms of patient satisfaction and function, as demonstrated in many studies, most of them retrospective.IndicationsContraindicationsPitfalls & Challenges.